Obesity Surgery published an article by Alex Heylen et al., Belgium, about successful use of the OTSC System in revisional endoscopy against weight gain after bariatric gastric bypass surgery. They report on 94 obese patients who had undergone Fobi pouch gastric bypass, and because of a dilation of the gastro-jejunostomy suffered a marked but unintended weight gain. An endoscopic over-the-scope clip was used to narrow the pouch-outlet. The OTSC clip application was safe and efficient to reduce the pouch-outlet in all cases. Best clinical results were obtained by narrowing the gastro-jejunostomy by placing two clips at opposite sites, hence reducing the outlet of more than 80%. Preferably, the clip approximated the whole thickness of the wall to avoid further dilatation of the anastomosis. Between surgery and OTSC clip application the mean BMI dropped from 45.8 (+/-3.6) to 32.8 (+/-1.9). 3 months (mean 118 days, +/-46 days) after OTSC clip application the mean BMI was 29.7 (+/-1.8). At the second follow-up about 1 year (mean 352 days, +/-66 days) after OTSC clip application the mean BMI was 27.4 (+/-3.8).The authors conclude: "The OTSC clip for revisional endoscopy after gastric bypass is reliable and effective in treating weight gain due to a dilated pouch-outlet with favorable short- and midterm results."

Treatment of weight regain due to dilation of the gastrojejunostomy after bypass surgery

Bariatric surgery is an undisputed option for morbid obesity. However, the long-term failure rate after gastric bypass surgery is 20–35%, and even higher in super-obese patients (Buchwald H et al., 2004). A number of studies suggest that a weight gain may be due to the gradual enlargement of the stomach pouch or due to the dilatation of the gastrojejunal anastomosis because of overeating. Reoperation with reducing the pouch volume or shortening the common loop is one option (Mullady DK et al., 2009). Given the high morbidity (15%) and even mortality (1%) of any surgical intervention in these patients, alternative endoscopic methods have been proposed (Heylen AM et al., 2010). The OTSC System proved to be safe and efficacious here.

Treatment of anastomotic leakage and chronic fistula

Due to the postoperative impairment of the blood supply in the stomach and the usually impaired wound healing in obese patients anastomotic leakage, gastric band erosion, and fistula formation represent frequent and serious complications in bariatric surgery. The surgical treatment of these long-term complications is dangerous and burdened with a high morbidity and failure rate. The conventional endoscopic options are manifold but have their shortcomings too. The innovative OTSC System offers a completely new quality of treatment which adds to the degree of freedom for the interventionist even and especially in complicated cases.

Clinical case videos

Treatment of weight regain due to dilation of the gastrojejunostomy after bypass surgery

Source: Dr. A Heylen, CHU Brugmann, Brussels, Belgium

This video by Dr. A. Heylen shows the successful treatment of weight regain due to a progressive dilation of the gastrojejunal stoma. (Heylen AM et al., 2010) Two years after surgery they gained weight by around 10% or more again, faced reappearing comorbidities and an increased volume per meal or an increased frequency of meals. At this stage they were treated with two OTSC Clips (t version) to narrow the pouch outlet. Two OTSC Anchors were used to approximate the edges of the pouch.

Treatment of weight regain due to dilation of the gastrojejunostomy after bypass surgery, part II

Source: Dr. A Heylen, CHU Brugmann, Brussels, Belgium

In the first video (see above) the endoscopist narrowed the dilated gastro-jejunostomy by approximating the edges of both angles of the anastomosis. This would result in a correct width of the bypass in the center.In this video here, however, the author would approximate and clip only one angle using two consecutive OTSC clips which were placed in a row, right one clip next to the other. Like for the closure of large perforations the sheer tension of the tissue will suffice to also completely approximate the tissue between both clips.

Note: some authors use and recommend a single channel endoscope for this procedure. As application aid they use an OTSC Twin Grasper. This procedure will basically work where there is no major fibrotic tissue to be found in the gastro-jejunostomy.